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12078 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER aDILDIN ' APPLICATION'& PERMIT ADDRESS R 12078 . ..* BUILDING - ELECTRICAL-PLUMBING -MECHANICAL OwNER'S I PLAN CHECK VALIDATION �•� NAME 0� 1`rt Ll 11' ELECTRIC PERMIT FEE / PHON91'1 r NAME C ° MQ `, OUTLETS-SWITCHES-RECEP '10.00/1.00 •1 .I. y ur `rJ 11C a LIGHTING FIXTURES. 10.00/1.00 CONTRACftAk APPLIANCES:RESIDENTIAL ' ,4.00 ADORE '11 :' 1{ �� 1''''1I �� 1 ( • HONE Y \JI PANELS 10.00 DATE OF APPLICATION � ARCHITEcT - PANELS (OVER 200 AMP) - 20.00 PLAN CHECK FEE P.C.NO. OR ENGINEER uc.NO. - SIGNS TRANS. 3.00 ADOHOSs ENG. - SPECIAL CIRCUIT 5.00' PERMIT VALIDATION ' ,i,P EMP. METER OR POLE INS. 20.00 APPUDFNT'S MOTORS SEE FEE SCH. ADDRESS - (, ' SERVICE CHANGE 20.00 ( V a ocri - / Foo LICCNSI:D CONTRACTORS DECLARATION` ' u U I hereby affirm that 1 a e'licensed under provisions of Chapter 9 -' ISSUANCE DATE wG i (commencing with Section 7000)of Divisiqq 3 of B ne .yn4 _ BLDG. ELECT. PLG. MECH. F H z 1'rol'essions C dY vu I'rouse is in 1'ulf tont a efl�ce -S ❑ ❑ ❑ x O m - License Class L-1 _4 "a ¢ DER nECLA RATION BUILDING PERMIT - m w o - INFORMATION w; A'y .1 hereby affirm that 1 am exempt from the Contractor's License MISC.- - REFER TO ORD u O a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE > 10.001VALUATION $/FT. L' Nu'-` Code:.Any city or county which requiresa permit to construct.alter, _ ' QQ j FO Improve,demolish,Dr repair any Structure,prior to Its IsmanCe,aISO ELEG CONTR. LIC.NO. ELEC. O u requires the applicant for such permit to file u signed str eet that _ TOTAL PERMIT TO ' a w m he is licensed pursuant to the provisions Of the Contractor's License - / F i< Law(Chapter 9(commencing with Section 700()o'Division 3 ofthe La Business and Professions Code)or that he is exempt therefrom and CITY. .PLUMBING PERMIT FEE (� ¢r$ the basis for the alleged exemption.Any violation of Section 7031.5 _ STORIES TYPE CONSTR. uby any applicant for a permit subjects the applicant tort civil penalty ALTER-DRAIN -WATER (EA.) 5.00 of riot more than five hundred dollars($500).): ❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS their sole compensation,will do the work,and the structure is not intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:'the Contractor's License Law does not upply.to an owner of Property who builds or improve$thereon,and who does such work FIXTURES-PER TRAP5,01) SD,FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- - .. ,vents are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00 • or improvement is Sold within one year of completion, tiro DwncP GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE. a builder will have lire burden of proving that he did not build or int RES IND CON PB Osne, ❑ . . prove for purpose ofsale.). INDUSTRIAL WASTE INTER - 3000 � 1,as owner of the property,:un exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed contractors to construct the Project(See. 7044,Business LAWN SPRINKLERS- I INC5 V.B. 6.00 ASSESSORS PARCEL NO. and Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 - contracts for such projects with a contractor(s)licensed pursuant toSEWER-SAN V-STORM EA.200ft/10.00 the Contractor's License Law. TRACT NO, PARCEL NO. ❑ 1 ons exempt under Sec. ,B.&P.C.for this WATER HEATER W/V ENT 6.00 reason Owner Uate WATER SYSTE - 5.00 - ACC.DATE ACC.FILE NO. WORK IiRS'COM PI!NSAlTON DECLA RATION WATER TREATING EQUIP. 5.00 - 1 herehy affirm that I have a certificate of corse t In set GIRS".' - ZONING' ENG.SITE NO. ora ertifica of W ken'C ti n,1ns a or a cert"red JAN 2 M7 c. 1111 0 15 ted pis hereby FIRE$PRINK 'ENERGY T-24O Certified c is fed i r B c'y 'nsp ti inion. Z MISC.- REFER TO ORD. O Applicant Y ❑ N❑ Y ❑ N❑ ~ N - - 10.00 ' CC CIiRTIF f F,OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE r FLOOD ZONE A.L.ILC. LU - OMPF.NSATION INSURANC17PLG.CONTR. LIC.NO. - PLG. Y N V❑ NE]CL O (This section need not he completed if lire permit is for one TOTAL ❑ 0 Z hundred dollars($100)or less,) U O ,I certifylhat in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY IL F. mit is issued.I shall not employ any person in any manner so as to V become subject to the Workers'Compensation Laws of California. y Date Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING �- tri, NOTICE TO APPLICANT': If,after nwking this Certificate of fix- F Z 'emplion,you should become subject to the Workers'Compensation APPLIANCE ;5.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with FEE U such provisionsor this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 , CONSTRUC-I'[ON LENDING AGENCY AIR HANDLING UNIT(OVER 10=CF.M.) 6.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 - the performance of the work for which this permit is issued(Sec. MICROFILM .3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name Address Lender's AddrHEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC /-= I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 (� information is correct. 1 agree to comply with all city and county PLUMBING O• ordinances and store'laws relating to buildirig construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 hereby authorim representatives of this city lo.rimer-upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH: MECHANICAL above-mentioned properly for inspection purposes. (We) agree to save, indemnify and keep harmless lire City of MISC.- REFER TO ORD. Cupertino again liabilities,judgments, costs null expenses which - - CONST.TAX y in any a come against'said City in cm a encu of t e MECH.CONT. LIC. ISSUANCE"' '10.00 m ting f[h aIC.ND. MECH. - of a' TOTAL TOTAL ©• l S' n are D Ap cat on rector Pate - OFFICE COPY - -